Forms

The following forms are available:

• AIM Preauthorization/RQI Request Fax Form
• Connections Physician’s Referral Form — for eligible members
• Continuation of Care Form
• Direct Ship Injectables Request Form
• Emergency Room Review Form
• Healthy Lifestyles Keys to Wellness Referral Form
• HIPAA Authorization Form — authorizes Independence Blue Cross to release member’s health information
• HIPAA Personal Representative Form — appoints another person as member’s personal representative
• Member Consent For Financial Responsibility Form
• Non-Formulary Exception Request Form
• Overpayment Refund Form
• PCP to Behavioral Health Provider Form
• Physician Certificate of Attestation Form
• Physician Claim Inquiry Form
• Populated Sample CMS-1500 (08/05) Claim Form with Instructions
• Prior Authorization Forms for prescription drugs
• Provider Change Form
• Surgical Team (Modifier -66) Documentation Form

Additional provider forms are available by calling the Provider Supply Line at 1-800-858-4728.